Course Review: The Eclectic Approach UE and LE Assessment and Treatment

Last weekend, I had the pleasure of meeting and taking the course from the one and only themanualtherapist.com, Dr. Erson Religioso III at Perfect Stride Physical Therapy. I’ve been following his blog for 2+ years and it was great to finally meet him.

The course was excellent overall where Dr. E has allowed me to open my eyes to approaches that I was not a big fan of.   I’m not going to write about the whole course but I want to jot down some pointers that I received through out the course.

He started off the course introducing his background and training. While introducing he did A LOT of pain science education. I like a teacher that explains about pain science. You can feel the energy of the room become lighter because it decreased all our threat perception. I was extremely pleased to hear that everything he does is from a neurophysiologic standpoint (including McKenzie End Range Motions), which resonated well with me.

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Adding this to my pain science library

Rest of the weekend included assessment and treatment of the UE/LE utilizing tools such as:

Assessment – SFMA and Repeated Motion Testing

Treatments – Pain education, Home Exercises, Repeated Motion, IASTM and manipulation.

Key Pointers:

“The biggest difference between you and I is our mouths”- in respect to how we educate and interact with our patients

“I’m evidence lead” <—loved this

“Modern pain science is about setting a painful experience into a positive experience”

“Manual therapy effects has been researched to last for 1~2 hours at best. HEP is a must to keep the therapeutic effect”

“Learn how to decrease the threat of the movement”

By doing the above, the Repeated Motions will become more effective:   “End range is where the magic happens”. Or “non-threatening end range is where the magic happens”. He reiterated end range is when the neurophysiological reset happens

end range Dr E

End Range!!

“Manual Therapy and exercise are powerful together. Manual therapy, exercises and EDUCATION are even more powerful.”

“Give simple home exercises AND self assessment tools. “


The big take homes points for myself was learning how to get into end range repeated motions. When he explained to the class that he wants to get to end range in a non-threatening way resonated with me much more since it is in alignment with the modern pain research. Many times in the past, I would stop performing repeated motions since the pain continuously got worse or if it did get better extremely high repetitions had to be performed (>200 prone press ups) even to see a result. I was a little too impatient for that.

However, Dr. E utilizes other techniques such as PNF, mobilization/manipulation, IASTM to decrease the nervous systems threat, which allowed the individual to achieve end range quicker and with less pain. When it did reach end range, we did see results repeatedly.

I’ve been utilizing his techniques this week and the results have been very pleasing. My huge goal as a clinician is to start giving self-assessment tools to patients, which I strongly believe will improve my patient compliance. In the end, we are their coaches and our goal as physical therapist is to make them independent.

In summary, I was extremely impressed with his ability to make complex things into such a simple manner and be effective.   That’s a sign of a great educator.

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Thanks Dr. Erson! I hope to see you in the summer!!!

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When do I become normal again!??: High Heel Case

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“When will I be normal again?”

This is a common statement I hear from my patients.  Usually this depends on what the individual’s perception of ‘normal’ is but I want to focus on a case study today.

I’m currently treating a runner who started running marathons 4 years ago for her R knee pain.  Her knee is painful while walking in heels, stairs, squats, single leg squats and after running.

I’ve found several movement dysfunctions along with surgical scars from 4 years ago.  After 2 visits, her R knee has significantly improved and was able to single leg squat without pain.  I advised her to start running again while performing home exercises to keep her impairments at bay.  She has been able to run 5~8 miles without pain.

Then one visit, she came in complaining with increased R knee pain reporting she was wearing heels all day and her knee started to hurt.  Through her movement patterns assessment, I educated her wearing heels for prolonged periods may create unnecessary knee torque.

Thats when she replied frustrated:

“When will I be normal again able to wear heels all day!!”

Me:

patients name, is wearing heels normal to the body?”

Try walking on your toes.  For more than 5 minutes straight.  Your calves burn and your feet start to become sore.  Try that for a 6~8 hour work day.

When you plantar flex your foot for prolonged periods, you will compensate and you will lose stability which may lead to injury.

If you want to wear heels make sure you get assessed and receive the correctives so you can protect your feet.

My patient reported pain progressively decreased after she was out of her heels (i wonder why)

Heels are great but you maybe paying the price.  Know the consequences.  Make sure you get assessed.

I’ll be posting about ankle sprains in the near future since I’ll be leading a study group regarding ankle sprains.  Stay tuned!!!

Missing Ingredient to Rehabilitation

MissingPiece

What are we missing?

Here is the truth when it comes to rehabilitation: there is no single formula to follow that will guarantee improvements or no pain in few visits or 1 day.  With physical therapy and the rehabilitation world emphasizing on research there are many so and so called ‘protocols’ now.

Don’t get me wrong, protocols are great and it has given me results.  However, although it may be specific to a diagnosis, protocols are a general way to treat a certain condition. I quote Dr. Andreo Spina when I took his Functional Range Release course (I’ll be taking the Upper Extremity one in January by the way):

“When you treat generally, you get a GENERAL result.  If you treat with specific intent, you get a SPECIFIC result.”  

This means that protocols are great because it will work majority of the time but countless times I would hit a road block with my patients.

So….. what was lacking?

Personalization.   Personalization, to me is usually the missing ingredient.   Not this amazing manual therapy technique or a modality.  Its the ability to assess a patient, find what the individual needs and base a rehabilitation process out of it.  I’ve found that even two people who come to my office with the SAME EXACT diagnosis need vastly different solutions or interventions.

Once the program is individualized, then the manual therapy technique may improve its efficiency by ten fold.

When I stopped assuming how a patient may present with certain diagnosis (i.e.- herniated disc), I started getting much better results.  I objectively assessed and treated what I found.

Research, protocols and general treatments are great and I still use them as a guideline because it can give me a pattern to certain diagnosis.  However, I don’t want to forget that I’m treating YOU as an individual and not as a diagnosis.

I mean, what patient wouldn’t like an individualized program anyway?  The retention rate will probably go up too since they know you specially made it for them:).

Breathing and Shoulder Dysfunctions

thanksgiving

Happy Thanksgiving Everyone:)  I’m going to keep this short and sweet.

Since I’ve been writing about breathing, I want to discuss about how breathing dysfunctions can lead to shoulder injuries.   In our previous blog we talked about the importance of breathing into the diaphragm which can be found here.

When an individual is inefficiently using the diaphragm, it will use other musculatures to breathe because the body will always pick survival.   Common patterns would be to breathe into the chest and neck.   For the shoulder, especially the pectoralis minor is a good one.

pecminor

You crazy muscle you.

If you take a look at the muscle above, the muscles has connections to the ribs 3-5.  Their function is to lift the ribs during inhalation.  On the other hand, it brings the scapular/shoulder blade into anterior tilt.

If an individual continues to breathe through the chest chronically, the pec minor muscle will adapt and stay shortened.  This may create an increased amount of scapular anterior tilt on the scapula which may cause dysfunctions to the shoulder.

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Seen these postures before??

OR it can lift the ribs and lead to rib flares. Like below.

flared-ribs

These can also affect the core and low back but thats for another post.

Nevertheless,this is an extremely common pattern but many miss how an individual breathes can cause the dysfunction.  Especially when giving correctives, its important to give an individual breathing exercises so the corrections ‘stick’.  You release the pec minor and if you continued to chest breathe, the muscle will always stay toned.

So….

Are you checking breathing with individuals with shoulder issues?

If you have any shoulder issues get it checked out by practitioners who have a systematic way of looking at the body such as but not limited to: SFMA, DNS, PRI, NKT, etc.

Happy Thanksgiving!

The Importance of Breathing- Diaphragm Edition

As I finished watching Gray Cook and Dan John’s Essential Coaching and Training Continuums, I was happy to hear the knowledge bombs Gray and Dan was exploding about breathing.  Breathing is a multifactorial action which can be talked about for days.  For this post’s purpose, I’m going to talk mainly about the diaphragm.  Just don’t forget breathing can also affect different areas of the body such as: intrinsic core musculature – low back, hip, pelvis, pelvic floor, neck, jaw, eyes, shoulder, autonomic nervous system, and internal organs.

Anyway, enough about the other things.  Lets get into the diaphragm:

diaphragm_semidiagrammatic

You are so magnificent diaphragm

Diaphragm:  The primary inspiratory muscle when concentrically loaded

The diaphragm is situated between the organs like a supple layer which fits between them and takes their form.  It is shaped like a large irregular dome.

Action: The primary action to the diaphragm is respiration and aids in compressing abdominal viscera (abdominal press)

Innervation:  Phrenic Nerve from C3-5 Cervical Plexus

Insertion:  Central Tendon

Origin:

     Costal Part- 7-12th ribs (inner surface; lower margin of costal arch)

     Lumbar Part – L1-3 vertebral bodies, intervertebral disks, and anterior longitudinal ligament as right and left crura

     Sternal Part-  Xiphoid Prcoess

Miscellaneous:

Muscular slips intertwine with fibers of the TVA.   Med and Lat Arcuate ligaments forms a fibrous arch between T/L Fascia, psoas, crus and QL!!

Man!!  The diaphragm has fibrous connections with TVA, psoas, T/L fascia and the QL??  Did it also state that it had connections with the intervertebral disks?  Utilizing the diaphragm/breathing mechanics can affect the above mentioned structures directly.  I’ve seen this time and time again in my clinic and improving breathing mechanics is a vital part of back/SI and hip rehabilitation.

When you are moving/working out, check how you are breathing because you might be compromising the stability you are suppose to be making naturally.

Breathe into your abdomen/lower ribs and back when you breathe in.  Create that 360 corset that Stuart McGill, the leading researcher of the spine has preached about.

Use the diaphragm.  Create stability.  Get stronger with integrity.

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References:

Atlas of Anatomy 2nd Edition 2012

 

The 4 B’s – Gray Cook/Dan John/Lee Burton

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If you don’t know me well, I’m a big fan of Gray Cook.  He is a visionary that knows how to explain the complicated into a simple manner.  I’ve listened and watched many of his videos but just haven’t got to meet him in person yet.  One day!!

I’m in the process of finishing the video Coaching and Training Essential Continuum and I highly recommend it.  He talks about the coaching and training continuums, how the FMS/SFMA fits in there, certain exercise examples, etc with Lee Burton and Dan John.

However, I want to point out one of the things that he mentioned that I LOVED.  Which were the 4 B’s:  Breathe, Bend, Balance and Bounce.  In order of priority.  My blog is fairly new; however if you knew me in person you would know how much I emphasize the importance of breathing with my clients and myself.

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Amen to this pic

He emphasized for all movements you must ask: Can the person breathe efficiently (more specifically diaphragmatically)?  Can they bend (have enough range of motion)?  Do they have balance (strength/balance/work capacity)?  And then you can go to BOUNCE (running, jump rope, KB swing, jumping, any ballistic activity).

There are many times we want to go to the fancy exercises because its “cool” or its “functional”.   Thats fine if the individual has the BASICS (another B eh?) before you get to those exercises.  Make sure you individualize an exercise (progress or regress) so they are at their neural edge and needs minimal coaching.  If you realize the exercise itself is very difficult go back to the 4 B’s again.  If they clear all that, they qualify for the exercise.

Too many of us get confused about the fancy exercises and they get stuck because the patients are just not plain ready for it.  You just waste time.  Oddly enough (NOT) Gray’s 4 B’s are the answers many times.

If you have further interest, go to movementlectures.com.  It’s an awesome website with great content.

There is no right or wrong.   You can be the judge of that.

But I do have to ask, are you looking at the 4 B’s as you progress?

Are you a manual therapy junkie?

 

Today’s post are my thoughts on how to develop as a clinician.

As I develop as a clinician and as an educator many students ask me this question:

What manual therapy courses should I take?  Should I take mulligan? rocktape? ART? graston? gua sha? etc. 

 

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My answer are usually as follows:

All will be beneficial but if you don’t assess before you treat, you’re just shooting bullets without a target.  Learn a systematic approach first if you can.  Then your treatments will become exponentially more valuable.  

I’ve meet clinicians who has been in practice for years who have taken an array of manual therapy courses.  Their hands on skills were phenomenal but there was one thing that was common.  They lacked a systematic thought process.  They seemed to lack the why.  Or the ability to explain the why.   Since they had many tools in their toolbox, it was either try a new technique -> didn’t work -> try different technique -> and so on.  This is along the lines of “shoot enough bullets and you eventually will hit the target” When this happens, you maybe wasting a lot of time.

A philosophy and system guarantees you some level of success in what you are doing because you have a way of operating. People in the profession who inspire me the most always have a way of working and a method of operation. I learned the importance of this process from the experts in the field directly or indirectly such as Mike Reinold PT, DPT, Charlie Weingroff PT, DPT, Gray Cook PT, Patrick Ward LMT, Kathy Dooley DC, and Perry Nikelston DC.

Some other benefits from a systematic approach includes:

1.  It will guide you if a patient/client will benefit from your treatments

2.  The ability to understand the whys of how the individual is hurt or moving improperly.  (I.E.- Why can’t the patient touch his toes?  Is it a mobility issue or a stability? You would not know this unless you ASSESS).

3.  The systematic approach will guide you if you need to refer out.

4.  A system allows you to integrate other techniques more flawlessly and guides you WHEN and WHERE to use the techniques.

Regardless, I do want to note that there are no absolute right or wrong way.  However, having a systematic approach may be better.  So I ask you these questions:

How do you assess? How do you evaluate? How do you train/treat?

Before you take another manual therapy course, you must ask yourself what your philosophies and your approaches are.  My philosophies are to understand why things are happening so I can eventually educate my clients and patients to learn how to help themselves.  I’m only a catalyst/guide to get them there faster.   My systematic approach includes SFMA, NKT, Movement Impairment Syndromes and FRR Palpation systems.  They all have allowed me to zone in on the issues and learn what and how to treat them.

I hope this helps.

In the end,

It’s your decision.

Note: I haven’t blogged in a while and I apologize.  I WILL at least blog once a week.  It doesn’t matter if it is a thought that I was thinking or an actual article I want to write.  I know by writing and putting my ideas together will be a benefit for me and if it benefit others, what more can I ask for?